1881733558 NPI number — AMY KRISTEN MICKLER MD

Table of content: MRS. ALEXIS TOMCZYK DC (NPI 1134090475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881733558 NPI number — AMY KRISTEN MICKLER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MICKLER
Provider First Name:
AMY
Provider Middle Name:
KRISTEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIDDLE
Provider Other First Name:
AMY
Provider Other Middle Name:
KRISTEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1881733558
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 917368
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-793-9300
Provider Business Mailing Address Fax Number:
727-793-0661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1106 DRUID RD S
Provider Second Line Business Practice Location Address:
DEPARTMENT OF RADIOLOGY
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33756-3846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-441-3711
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  135564 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: ME98736 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 278336300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00427228 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 90739 . This is a "BCBSFL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 278336300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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